HCV Bright Future Needs Primary Care Docs

In this guest blog, Hugo E. Vargas, MD, chair of the division of hepatology at Mayo Clinic in Phoenix, Ariz., urges primary care doctors to get excited about the potential for hepatitis C treatment and cure.

The field of hepatology finds itself at a pivotal moment in its history.

We have long recognized hepatitis C virus (HCV) as a masterful foe that evaded many efforts to stop the slow devastation that it yields without successful treatment. As we enter an exciting era with promising new treatments and essential screening mandates, the conversation becomes bigger than our field. I recently authored an article on this topic for my GI and hepatology colleagues in AGA Perspectives, the American Gastroenterological Association's bimonthly magazine; however, given the recent advances, it's time we extend this conversation to our primary care colleagues. We will not be able to treat the 5 million HCV-infected Americans without your help.

Since the onset of my clinical efforts more than 20 years ago, I have toiled with a long, challenging HCV therapy anchored on the use of interferon, which, pegylated or not, limited my ability to incite enthusiasm even in the most motivated of patients. We are now entering a hopeful era when we will eliminate interferons as a base for our treatment approach and broaden the spectrum of patients we can treat safely. With this promise in front, the question can be fairly asked: how will we define our success?

We have long known that a vast majority of our potential patients have no idea they can be at risk for a viral infection that is insidious and costly to manage once it has played out its course. The valuable data gleaned from the National Health and Nutrition Examination Survey places the national (excluding homeless and institutionalized people) prevalence of HCV infection at 1.5 percent. Adjusting for those not accounted for in the surveys, we estimate that 4.5 to 5 million Americans may be infected with the virus. One may ask, if these numbers are known, why is there a problem? The sad truth is, among those infected, 45% to 85% are not even aware of their "at-risk" status and thus lack the motivation to seek screening. Some reports place the prevalence of HCV testing in these groups as low as 17 percent. The American Gastroenterological Association recently released a useful clinical decision support tool to guide physicians through hepatitis C screening and evaluation -- but the issue remains, we cannot treat patients who do not seek screening.

This is why the current CDC recommendation to include non-risk-based, one-time testing of all adults born between 1945 and 1965 is an important step to address this deficiency at a timely point in history. This birth cohort, commonly referred to as the "baby boomer" generation, accounts for a disproportionate 76.5 percent of all HCV-infected Americans.

The CDC recommendation arrived at the same time as the impressive headlines of new, potentially all-oral direct antiviral regimens claiming fantastic viral responses in the range of 85 to 95 percent in phase II and early phase III data. Data presented at this year's Digestive Disease Week, and simultaneously published in the New England Journal of Medicine, also highlighted the potential of interferon-free regimens to greatly improve response rates in HCV.

It is difficult to contain the excitement of seeing interferon-free options for even my sickest patients come to light, coupled with a recommendation to bring the largest group in society to benefit from treatment and education about the effective treatments available to them.

Does this mean that the work of hepatology is done? My answer is a resounding NO! We have to recognize that, however effective, treatment of 5 million Americans will not be easy. Many do not have access to care. Importantly, those incarcerated may return to society with unrecognized disease, unrealized medical coverage, and will remain a seedbed for future infection. Recent reports from CDC reveal both that injection drug use may be leading to a new wave of infections in younger populations and increased incidence of HCV in men who have sex with men who are infected with HIV. Further, for those patients who are willing to be treated presently, the cost of therapy may exceed $100,000.

Success will be defined by how we overcome all those challenges and advocate for our patients, support our primary care colleagues, and expand the pool of HCV treating clinicians to fully manage the enormous need.